Managing Acute & Chronic Pain with Opioid Analgesics in ...pcssnow.org/wp-content/uploads/2015/12/Alford-Acute-Chronic-Pain-MAT... · Managing Acute & Chronic Pain with Opioid Analgesics
Post on 18-Oct-2019
1 Views
Preview:
Transcript
Managing Acute & Chronic Pain with
Opioid Analgesics in Patients on
Medication Assisted Treatment (MAT)
Daniel P. Alford, MD, MPH, FACP, FASAM Associate Professor of Medicine
Assistant Dean, Continuing Medical Education
Director, Clinical Addiction Research and Education Unit
Boston University School of Medicine & Boston Medical Center
1
Daniel Alford, MD, Disclosures
• Daniel Alford, MD, has no financial relationships to
disclose.
The contents of this activity may include discussion of off label or investigative drug uses. The
faculty is aware that is their responsibility to disclose this information.
2
ASAM Lead Contributors, CME Committee
and Reviewers Disclosure List
Name
Nature of Relevant Financial Relationship
Commercial
Interest
What was
received?
For what role?
Yngvild Olsen, MD, MPH None
Adam J. Gordon, MD, MPH,
FACP, FASAM, CMRO,
Chair, Activity Reviewer
None
Edwin A. Salsitz, MD,
FASAM, Acting Vice Chair
Reckitt-
Benckiser
Honorarium Speaker
James L. Ferguson, DO,
FASAM
First Lab Salary Medical Director
Dawn Howell, ASAM Staff None
3
ASAM Lead Contributors, CME Committee
and Reviewers Disclosure List, Continued
Name
Nature of Relevant Financial Relationship
Commercial
Interest
What was
received?
For what role?
Noel Ilogu, MD, MRCP None
Hebert L. Malinoff, MD,
FACP, FASAM, Activity
Reviewer
Orex
Pharmaceuticals
Honorarium Speaker
Mark P. Schwartz, MD,
FASAM, FAAFP
None
John C. Tanner, DO,
FASAM
Reckitt-
Benckiser
Honorarium Speaker and consultant
Jeanette Tetrault, MD,
FACP
None
4
Accreditation Statement
• The American Society of Addiction Medicine
(ASAM) is accredited by the Accreditation Council
for Continuing Medical Education to provide
continuing medical education for physicians.
5
Designation Statement
• The American Society of Addiction Medicine
(ASAM) designates this enduring material for a
maximum of one (1) AMA PRA Category 1 Credit™.
Physicians should only claim credit commensurate
with the extent of their participation in the activity.
Date of Release: December 22, 2015
Date of Expiration: July 31, 2018
6
System Requirements
• In order to complete this online module you will need
Adobe Reader. To install for free click the link below:
http://get.adobe.com/reader/
7
Target Audience
• The overarching goal of PCSS-MAT is to make
available the most effective medication-assisted
treatments to serve patients in a variety of settings,
including primary care, psychiatric care, and pain
management settings.
8
Educational Objectives
• At the conclusion of this activity participants should be able to:
Describe the epidemiology of pain among individuals with opioid use disorder and factors that influence the overlap
Contrast the key role of patient and provider perspectives on pain management
Discuss general principles of and different specific approaches for acute and chronic pain management in patients with opioid use disorder treated with methadone, buprenorphine, or naltrexone
9
Epidemiology
• 52% of treatment seeking opioid-dependent
veterans complained of moderate to severe
chronic pain
• 37%-61% of patients taking methadone for
opioid use disorder have chronic pain
• Pain plays a substantial role in initiating and
continuing illicit opioid use
Trafton et al. 2000, Jamison et al. 2000, Rosenblum et al 2003
Karasz et al. 2004, Sharpe Potter J et al. 2010
10
Chronic Pain not Associated
with Worse MAT Outcomes
• Prospective study of office-based buprenorphine treatment
• Comparing treatment retention and opioid use among
participants with and without pain
• Among 82 participants, no association between pain and
buprenorphine treatment outcomes
• Conclusion: The presence of chronic pain in patients with
opioid addiction is not a barrier to successful opioid
addiction treatment
Fox AD et al. Subst Abus. 2012;33(4):361-5 11
Altered Pain Experience
• In experimental pain studies…
Patients with active opioid use disorder have less pain tolerance
than peers in remission or matched controls
Patients with a h/o opioid use disorder have less pain tolerance
than siblings without an addiction history
Patients on opioid maintenance treatment (i.e. methadone,
buprenorphine) have less pain tolerance then matched controls
• Methadone-maintained women had increased pain and
required up to 70% more oxycodone equivalents after
cesarean delivery Martin J (1965), Ho and Dole V (1979), Compton P (1994, 2001), Meyer M (2007)
12
Pain and Addiction
Provider Perspective
1. Physicians Fear Deception Physicians question the “legitimacy” of need for opioid analgesics (“drug seeking” patient vs. legitimate need).
“When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. It’s that seeking behavior that puts you off, regardless of what’s going on, it just puts you off.”
-Junior Medical Resident
Merrill JO, et al. J Gen Intern Med. 2002 13
Pain and Addiction
Patient Perspective
2. No Standard Approach Patients perceive that the evaluation and treatment of pain and withdrawal is extremely variable among physicians. This may be because there is no common approach nor are there clearly articulated standards.
“The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days.. . .This crew was hard! It’s like the Civil War. ‘He’s a trooper, get out the saw’. . .’”
-Patient w/ Multiple Encounters
Merrill JO, et al. J Gen Intern Med. 2002 14
Pain and Addiction
Patient Perspective
3. Avoidance
Patients perceive that physicians focus primarily on familiar acute medical problems and evade more uncertain areas of assessing or intervening in the underlying addiction problem-particularly issues of pain and withdrawal.
Patient/Resident Dialog Resident: “Good Morning” Patient: “I’m in terrible pain.” Resident: “This is Dr. Attending, who will take care of you.” Patient: “I’m in terrible pain.” Attending: “We’re going to look at your foot.” Patient: “I’m in terrible pain.” Resident: “Did his dressing get changed?” Patient: “Please don’t hurt me.”
Merrill JO, et al. J Gen Intern Med. 2002 15
Pain and Addiction
Patient Perspective
4. Patient Fear of Mistreatment Patients are fearful they will be punished for their drug use by poor medical care.
“I mentioned that I would need methadone, and I heard one of them chuckle. . .in a negative, condescending way. You’re very sensitive because you expect problems getting adequate pain management because you have a history of drug abuse. . .He showed me that he was actually in the opposite corner, across the ring from me.”
-Patient
Merrill JO, et al. J Gen Intern Med. 2002 16
Opioid Agonist Therapy
&
Acute Pain
General Principles
17
• Patients who are physically dependent on
opioids (i.e. methadone or buprenorphine) must
be maintained on daily equivalence before ANY
analgesic effect is realized with opioids used to
treat acute pain
• Opioid analgesic requirements are often higher
due to increased pain sensitivity and opioid
cross tolerance
Peng PW, Tumber PS, Gourlay D: Can J Anaesthesia 2005
Alford DP, Compton P, Samet JH. Ann Intern Med 2006
“Opioid Debt”
18
Methadone
Maintenance
&
Acute Pain
19
Acute Pain
Methadone Maintenance Treatment (MMT)
• Methadone maintenance dosed every 24 hours
does not confer analgesia beyond 6-8 hours
• Opioid analgesics will not cause excessive CNS
or respiratory depression due to opioid cross-
tolerance
• Risk of relapse to active drug use may be higher
with inadequate pain management than with the
use of opioid analgesics
Alford DP, Compton P, Samet JH. Ann Intern Med 2006 20
Acute Pain
Methadone Maintenance Treatment (MMT)
• Compared 25 post-surgical MMT patients who had
received opioid analgesics to 25 MMT patient controls
matched for age, sex, duration on MMT
• After 20 month follow-up, no difference in relapse
indicators such as substance use patterns and methadone
dose changes
• Conclusion: Opioid analgesics may be used safely in MMT
patients with acute post-surgical pain without
compromising addiction treatment
Kantor TG et al. Drug and Alc Dependence. 1980 21
Acute Pain
Methadone Maintenance Treatment (MMT)
Clinical Recommendations
• Continue usual verified methadone dose
• Treat pain aggressively with conventional analgesics,
including opioids at higher (1.5 times) doses and shorter
intervals
• Avoid using mixed agonist/antagonist opioids (e.g.,
butorphanol (Stadol)) as they will precipitate acute
withdrawal
• Careful use and monitoring of combination products
containing acetaminophen
Alford DP, Compton P, Samet JH. Ann Intern Med 2006 22
Methadone
Maintenance
&
Chronic Pain
23
Chronic Pain
Methadone Maintenance Treatment (MMT)
The good news… • Analgesia (6-8 hrs) from methadone dose may be good test for
opioid responsive pain
• Analgesia for 24 hrs from methadone dose implies that pain is likely opioid withdrawal mediated pain
• Closely monitored in MMT e.g., drug testing, pill counts
• Methadone will block euphoric effects of opioid analgesics
The bad news… • MMT programs only able to dose once daily (some clinics will
dispense “split doses”)
• It is illegal to prescribe methadone for the treatment of addiction
• Prescribed opioid analgesics may interfere with drug testing in MMT e.g., opiates and semisynthetics
• Opportunities at MMT to divert prescribed opioids
24
Chronic Pain
Methadone Maintenance Treatment (MMT)
In an ideal world…
would be able to treat both opioid use
disorder and chronic pain with methadone
dosed TID or QID either in the MMT or in
primary care
25
Buprenorphine
Maintenance
&
Acute Pain
26
Buprenorphine as an Analgesic
• Parenteral and transdermal formulations approved
for pain, not addiction treatment
CANNOT be used off-label under Drug Addiction
Treatment Act of 2000
• Sublingual formulation approved for addiction, not
pain treatment
Can be used off-label
27
Buprenorphine as an Analgesic
• Small studies in Europe and Asia demonstrate analgesic efficacy of SL formulation (0.2-0.8 mg q 6-8 h) in opioid naïve post-operative pain
• CNS and respiratory depression ceiling effect
• Analgesic ceiling effect is UNCERTAIN
Differing data on analgesic ceiling effect in animal models
No published data indicating an analgesic ceiling in humans
Edge WG et al. Anaesthesia. 1979
Moa G et al. Acta Anaesthesiol Scand. 1990
28
Buprenorphine as an Analgesic
Dahan A et al. Br J Anaesh 2006
In 20 healthy volunteers…Doubling dose increased
peak analgesic effect by 3.5x while respiratory
depression remained unchanged
29
Acute Pain
Buprenorphine Maintenance Treatment
Theoretical Concern
• Buprenorphine (a partial mu agonist) may
antagonize the effects of previously administered opioids or
block the effects of subsequently administered opioids
• However…Experimental mouse and rat pain models
Combination of buprenorphine and full opioid agonists (morphine,
oxycodone, hydromorphone, fentanyl) resulted in additive or synergistic
effects
Receptor occupancy by buprenorphine does not appear to cause
impairment of mu-opioid receptor accessibility
Kogel B, et al. European J of Pain. 2005
Englberger W et al. European J of Pharm. 2006 30
Acute Pain
Buprenorphine Maintenance Treatment
Options
1. Continue buprenorphine and titrate short-acting opioid analgesic
2. D/c buprenorphine, use opioid analgesic, then re-induce
3. Divide total buprenorphine dose into every 6-8 hour dosing
4. Use supplemental doses of buprenorphine*
5. If inpatient, • d/c buprenorphine
• start methadone 20-40mg (or other extended-release, long-acting opioid)
• use short-acting, immediate-release opioid analgesics
• then re-induce w/ buprenorphine when acute pain resolves
Alford DP. Handbook of Office-Based Buprenorphine Treatment of Opioid
Dependence. 2010
Alford DP, Compton P, Samet JH. Ann Intern Med 2006
* Book SW, Myrick H, Malcolm R, Strain EC. Am J Psychiatry 2007 31
Buprenorphine
Maintenance
&
Perioperative Pain
Management 32
33 Stern, Elizabeth E., "Buprenorphine And The Anesthesia Considerations: A
Literature Review" (2015). Nurse Anesthesia Capstones. Paper
2. http://dune.une.edu/na_capstones/2
The “Five Day” Rule University of Michigan Protocol
• But this protocol…
Risks causing a disruption in the patient’s
recovery from opioid addiction by stopping
buprenorphine during high anxiety preoperative
period
Has never been evaluated and is based on a
theoretical concern of pharmacological
principles
34
Boston Medical Center
Management Guidelines
• Take last buprenorphine dose on the morning of the day
prior to the procedure
• Hold buprenorphine dose on day of surgery
• Pre-procedure: give single dose of ER/LA opioid (e.g.,
SR morphine 15 mg) on the day of procedure
35
Boston Medical Center
Management Guidelines
• Post-procedure: Opioid analgesics should be started
using standard dosing protocols but pain management
should be carefully monitored since patients with opioid
use disorder often have decreased pain tolerance and
cross-tolerance to opioid analgesics resulting in a need
for higher opioid doses and shorter dosing intervals
• Because of its high affinity at the opioid receptor Fentanyl
should be the opioid of choice for analgesia during
surgery and in PACU for these patients
36
Boston Medical Center
Management Guidelines
• Continue to hold buprenorphine
• All patients should be placed on an ER/LA opioid (e.g., SR
morphine 15 mg bid) to address the patients baseline
opioid requirements and for sustained pain control
• If patient also requires parenteral analgesia for
breakthrough pain control use PCA (fentanyl, dilaudid or
morphine) with NO basal dose. Continue ER/LA opioid
• If patient does not require parenteral analgesia for
breakthrough pain control use IR/SA opioids
e.g.,oxycodone, morphine. Continue ER/LA opioid.
37
Boston Medical Center
Management Guidelines
• Continue to hold buprenorphine
• All patients should be continued on ER/LA opioid
• Treat patient’s breakthrough pain with IR/SA opioids e.g.,oxycodone, morphine.
• Schedule patient to see their buprenorphine provider within 1 week to be considered for restarting buprenorphine maintenance
38
Does it need to be so
complicated?
Can it be as simple as managing
acute pain in methadone
maintained patients?
39
• 5 patients underwent 7 major surgeries (colectomy,
knee replacement, small bowel resection, bilateral
mastectomy)
• All maintained on stable doses of SL buprenorphine (2
mg – 24 mg) for chronic musculoskeletal pain – some
with remote history of opioid addiction
• By chart review, postoperative pain was adequately
controlled using oral or IV full agonist opioids
Kornfeld H and Manfredi L. Am J Therapeutics 2010
Acute Pain
Buprenorphine Maintenance Treatment
Case Series
40
Acute Pain
Buprenorphine Maintenance Treatment
Accumulating Research
• Observational study of peripartum acute pain management of buprenorphine (n=8) stabilized patients
Patients responded to additional opioid medication given for pain control
Jones HE et al. Am J Drug Alc Abuse 2009
• Double-blind RCT comparing IV patient-controlled analgesia (PCA) with buprenorphine and morphine alone and in combination for postoperative pain in adults undergoing abdominal surgery
In the combination group, buprenorphine did not appear to inhibit the analgesia provided by morphine
Oifa S et al. Clin Ther. 2009
41
Acute Pain
Buprenorphine Maintenance Treatment
Accumulating Research
• Sub-analysis of the MOTHER Study, no differences in pain management during delivery and the 1st three days postpartum for MMT (n=21) and BM (n=19)
Hoflich AS et al. Eur J of Pain. 2011
• Cohort of peripartum acute pain management of buprenorphine maintained (BM) patients (n=63) (44 vaginal
deliveries, 19 C-section) matched retrospectively with controls
BM patients had similar intrapartum pain and analgesia BUT experienced more postpartum pain requiring 47% more opioids following C-section
Meyer M et al. Eur J Pain. 2010
42
Acute Pain
Buprenorphine Maintenance Treatment
Accumulating Research
• Retrospective cohort of 1st 24 hours after surgery in 11 BM and 22 MMT patients on patient controlled analgesia (PCA)
No significant differences in pain scores, incidence of nausea, vomiting or sedation
No significant differences in PCA morphine requirements
Macintyre PE et al. Anaesth Intensive Care 2013 43
Acute Pain
Buprenorphine Maintenance Treatment
Accumulating Research
• Retrospective cohort of 1st 24 hours after surgery in 11 BM and 22 MM patients on patient controlled analgesia (PCA)
No significant differences in pain scores, incidence of nausea, vomiting or sedation
No significant differences in PCA morphine requirements
Macintyre PE et al. Anaesth Intensive Care 2013
Authors conclude…
“results confirm that continuation
of
buprenorphine perioperatively is
appropriate” 44
Buprenorphine
Maintenance
&
Chronic Pain
45
Chronic Pain Buprenorphine Maintenance Treatment
• Open-label study of 95 patients with chronic pain who failed
long-term opioids and were converted to sublingual
buprenorphine
• Mean buprenorphine dose 8mg/d (4-16mg) in divided doses
• Mean duration of treatment ~9 months
• 86% had moderate to substantial pain relief along with
improved mood and function
• 6% discontinued therapy due to side effects or worsening
pain
Malinoff HL, Barkin R, Wilson G. Am J of Thera 2005 46
Chronic Pain Buprenorphine Maintenance Treatment
• Systematic review
• 10 trials involving 1,190 patients
• Due to heterogeneity of studies, pooling results and meta-
analysis not possible
• All studies reported effectiveness in treating chronic pain
• Majority of studies were observational and low quality
• Current evidence is insufficient to determine effectiveness
of SL buprenorphine for treatment of chronic pain
Cotes J, Montgomery L. Pain Medicine 2014 47
Naltrexone
Maintenance
&
Pain Management
48
Oral Naltrexone Blockade
“Time-action of naltrexone in detoxified ex-opiate addicts using 25 mg IV heroin challenges after naltrexone 100 mg dose”
Verebey K. NIDA Res Monogr 1981;28:147-58
96% 87%
47%
49
Acute Pain
Overcoming Naltrexone Blockade
• Hot plate test after XR-NXT or placebo, rats
treated with opioid agonist (morphine, fentanyl,
hydrocodone)
• Naltrexone blocks analgesic effects of opioids at
conventional doses
• Naltrexone blockade can be overcome at 6-20x
usual dose resulting in analgesia without
significant respiratory depression or sedation
Dean RL et al. Pharmacol Biochem Behav 2008 50
Emergent Acute Pain and Naltrexone
Management
• Discontinue naltrexone
• Consult Anesthesia
Need to have healthcare providers specifically trained in the use of anesthetic drugs and management of respiratory effects of potent opioids
• Opioid analgesics (high dose) administered under close observation
Need setting that is equipped and staffed for cardiopulmonary resuscitation.
Need to prepared to establish and maintain a patient airway with assisted ventilation if needed
• Consider nonopioids and regional anesthesia
51
For more information on injectable naltrexone and pain management, call 1-888-235-8008 or visit Vivitrolsafety.com
Perioperative Pain Management
• Naltrexone will block the effects of co-administered opioid analgesic
PO naltrexone
− t ½ is 14 hours, d/c for at least 72 hours preoperatively
− 50% of blockade effect is gone after 72hrs
IM depot naltrexone
− peak plasma within 2-3 days, decline begins in 14 days
− If possible, delay elective surgery for a month after last dose
Vickers AP, Jolly A BMJ 2006
52
Percent of Pain-related Post-Marketing
AE Reports
Early P et al. Acute Pain Episode Outcomes in Patients Treated with
Injectable Extended-Release Naltrexone (XR-NTX)
presented as poster at ASAM 2013 annual meeting
Study funded by Alkermes 53
Health Economics Retrospective
Analyses
• Hypothesis: Frequent acute pain episodes that cannot be managed on
an outpatient basis could elevate ER & hospital utilization rates
• Studies: All (4) published national commercial insurance database
analyses
• Limitation: Studies were not RCTs; all used statistical case-mix cohort
adjustment.
• Aggregate XR-NTX-treated population: N=1,323 patients
• Compared to all approved alcohol or opioid use disorder oral agents,
• XR-NTX patients had:
No greater ER use;
Significantly and substantially fewer hospital admissions.
Early P et al. Acute Pain Episode Outcomes in Patients Treated with Injectable Extended-
Release Naltrexone (XR-NTX)presented as poster at ASAM 2013 annual meeting
Study funded by Alkermes 54
References
• Alford DP. (2006). Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med, 144(2): 127-134.
• Compton MA. (1994). Cold pressor pain tolerance in opiate and cocaine abusers: correlates of drug type and use status. J Pain Symptom Manage, 9: 462-473.
• Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend, 63: 139-146.
• Cote J, Montgomery L. (2014). Sublingual Buprenorphine as an Analgesic in Chronic Pain: A Systematic Review. Pain Medicine, 15: 1171-1178.
• Dahan A. (2006). Buprenorphine induces ceiling in respiratory depression but not in analgesia. British Journal of Anaesthesia, 96(5):627-632.
• Dean RL. (2008). Overriding the blockade of antinociceptive actions of opioids in rats treated with extended-release naltrexone. Pharmacol Biochem Behav, 89: 515-522.
• Englberger W. (2006). Reversibility of opioid receptor occupancy of buprenorphine in vivo. European J of Pharm, 534(1-3): 95-102.
• Fox AD. (2012). Pain is not associated with worse office-based buprenorphine treatment outcomes. Subst Abus, 33(4): 361-5.
• Hoflich AS. (2012). Peripartum pain management in opioid dependent women. European J of Pain, 16(4): 574-584.
• Jones HE. (2009). Management of Acute Postpartum Pain in Patients Maintained on Methadone or Buprenorphine During Pregnancy. Am J Drug Alcohol Abuse, 35: 151-156.
• Kogel B. (2005). Interaction of mu-opioid receptor agonists and antagonists with the analgesic effect of buprenorphine in mice. European J of Pain, 9(5): 599-611.
• Kornfeld H, Manfredi L. (2010). Effectiveness of full agonist opioids in patients stabilized on buprenorphine undergoing major surgery: a case series. Am J Therapeutics, 17: 523-528.
55
References
56
• Macintyre P. (2013). Pain relief and opioid requirements in the first 24 hours after surgery in
patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive
Care, 41(2): 222-30.
• Malinoff HL. (2005). Sublingual buprenorphine is effective in the treatment of chronic pain
syndrome. Am J of Ther, 12: 379-84.
• Meyer M. (2013). Intrapartum and postpartum analgesia for women maintained on
buprenorphine during pregnancy. European J of Pain, 14: 939-943.
• Moa G. (1990). Sublingual buprenorphine as postoperative analgesic: a double-blind comparison
with pethidine. Acta Anaesthesiol Scand, 34(1): 68-71.
• Oifa S. (2009). Effects of intravenous patient-controlled analgesia with buprenorphine and
morphine alone and in combination during the first 12 postoperative hours: a randomized,
double-blind, four-arm trial in adults undergoing abdominal surgery. Clin Ther, 31(3): 527-41.
• Peng PW. (2005). Review article: perioperative pain management of patients on methadone
therapy. Can J Anaesthesia, 52: 513-23.
• Rosen K. (2014). Sublingual buprenorphine for chronic pain: a survey of clinician prescribing
practices. Clinical J of Pain, 30(4): 295-300.
• Roux P. (2013). Buprenorphine/naloxone as a promising therapeutic option for opioid abusing
patients with chronic pain: reduction of pain, opioid withdrawal symptoms, and abuse liability of
oral oxycodone. Pain, 154(8): 1442-1448.
• Stern E. (2015). Buprenorphine And The Anesthesia Considerations: A Literature Review. Nurse
Anesthesia Capstones, Paper 2. http://dune.une.edu/na_capstones/2.
• Vickers AP. (2006). Naltrexone and problems in pain management. BMJ, 332(7534): 132-3.
PCSS-MAT Mentoring Program
• PCSS-MAT Mentor Program is designed to offer general information to
clinicians about evidence-based clinical practices in prescribing
medications for opioid addiction.
• PCSS-MAT Mentors comprise a national network of trained providers with
expertise in medication-assisted treatment, addictions and clinical
education.
• Our 3-tiered mentoring approach allows every mentor/mentee relationship
to be unique and catered to the specific needs of both parties.
• The mentoring program is available, at no cost to providers.
For more information on requesting or becoming a mentor visit:
pcssmat.org/mentoring
57
PCSS-MAT Listserv
Have a clinical question? Please click the box below!
58
Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or
organizations imply endorsement by the U.S. Government.
PCSSMAT is a collaborative effort led by American Academy of
Addiction Psychiatry (AAAP) in partnership with: American Osteopathic Academy of Addiction Medicine (AOAAM), American
Psychiatric Association (APA), American Society of Addiction Medicine (ASAM) and Association for Medical Education and
Research in Substance Abuse (AMERSA).
For More Information: www.pcssmat.org
Twitter: @PCSSProjects
59
Please Click the Link Below to Access
the Post Test for this Online Module
http://www.cvent.com/d/mfql0y
Upon completion of the Post Test:
• If you pass the Post Test with a grade of 80% or higher, you will be instructed to click a link which will bring you to the Online Module Evaluation Survey. Upon completion of the Online Module Evaluation Survey, you will receive a CME Credit Certificate or Certificate of Completion via email.
• If you received a grade of 79% or lower on the Post Test, you will be instructed to review the Online Module once more and retake the Post Test. You will then be instructed to click a link which will bring you to the Online Module Evaluation Survey. Upon completion of the Online Module Evaluation Survey, you will receive a CME Credit Certificate or Certificate of Completion via email.
• After successfully passing, you will receive an email detailing correct answers, explanations and references for each question of the Post Test.
60
top related